上次說到會跟大家介紹常見的安眠藥物,今天小布醫師就要來跟大家介紹一下,究竟惱人的失眠應該如何治療呢?
在開始介紹藥物治療之前,小布醫師要先端正大家關於治療失眠的目標的錯誤觀念。根據<Clinical Guideline for the Evaluation and Management of Chronic Insomnia in Adults>J Clin Sleep Med. 2008 Oct 15; 4(5): 487–504. 的定義,失眠的治療目標如下:
1. 提升睡眠品質
2. 改善失眠對白天所造成的影響
3. 減少入睡時間和醒來次數
4. 增加總睡眠時間
如何?根據這些治療目標,大家會不會在腦海裡閃過一個念頭:一定要靠吃安眠藥治療嗎?當然不是囉!在這裡小布醫師要先強調一個觀念:要改善失眠的問題,一定要調整自己不良的生活習慣、增加運動的次數與強度、注意飲食及身心健康狀態,最後才是藉由藥物的協助。但在台灣健保速食文化的荼毒下,一般民眾往往會忽略促進自身健康習慣的重要性,而把希望完全寄託在藥物的治療上面。除了廉價的醫療與藥物助長歪風以外,這樣的錯誤觀念也讓民眾容易誤會,以為失眠是一個單純的疾病,反正只要吃藥助眠就可以了,這完全是錯誤的觀念喔!
台灣人到底有多愛吃安眠藥呢?根據衛福部食藥署統計,2014年國人的安眠藥使用量已經高達三億三千九百多萬粒,創下史上新高紀錄,藥片串起來約等於一條中山高速公路加一條雪山隧道的長度,其中以能快速入睡的佐沛眠(Zolpidem)成分達一億三千七百多萬粒佔最多。這些數據顯示一般民眾在改變自己的健康習慣前,就已經先習慣藉由安眠藥物來治療失眠的問題。再加上藥物的取得比起用心理治療處理失眠背後的主因來的更容易、廉價,也漸漸養成大家習慣性在就醫的時候就開口跟醫師要求開立安眠藥。小布醫師過去在教學醫院擔任主任的時候,三不五時也會有病患根本不願意深談自己的心理困擾,僅僅是要求醫師開立越來越多的安眠藥物治療,小布苦口婆心勸個案的時候,還被個案嫌煩的經驗咧!
好啦,關於安眠藥物的使用,小布醫師囉嗦這麼多之後,現在要來幫大家介紹囉!俗稱的鎮定劑,安眠藥等,目前市面上廣為使用的都是一種BZD類的藥物。BZD中文翻譯作苯二氮類藥物,這類藥物會作用在人體中樞神經細胞上的GABA-A接受體上面,與α-1、α-2、α-3及其他次單元結合,透過打開氯離子通道使其進入細胞內,進而達到鎮靜、安眠、抗焦慮、抗痙攣或肌肉鬆弛的效果。很難懂對不對,小布醫師幫助大家白話文翻譯一下:BZD類藥物有鎮定安眠、抗焦慮,或肌肉鬆弛的效果,端看它是跟GABA接受體的哪一個部分結合囉!有些冰雪聰明的朋友會問,那為什麼吃安眠藥/鎮定劑的人不能飲酒呢?原因就是酒精也剛好會作用在這個GABA接受體上面,在高濃度時甚至可以直接打開氯離子通道,鎮定效果更快速喔!如果同時服藥又飲酒的話,會造成對於GABA接受體的刺激過度,氯離子大量流入細胞內,造成過度鎮靜的效果,甚至可能得送急診打解毒劑喔!
嘿嘿,小布醫師一定是沒注意到,那我們怕藥物成癮的人,直接喝酒助眠不是更直接?幹嘛那麼麻煩還要吃藥呢?或是只吃一顆安眠藥,配酒的話效果不是更快更直接?
NoNoNoNoNo!小布醫師在這邊嚴正聲明,喝酒助眠是很直接,但是因為您無法計算酒精+安眠藥物同時對於GABA接受體的影響,再加上剛剛提到的可能對GABA接受體過度刺激,這都有機會造成嚴重的中樞神經鎮靜作用:簡單說就是您會昏死過去啦!甚至會抑制自主呼吸的的功能喔!更何況,小布醫師還沒講到酒精成癮的副作用及後遺症哩,您忘了會造成腸胃道嚴重出血、胃潰瘍、肝硬化甚至是肝癌嗎?
所以啦,之後就有科學家發明了Z-drug (Zolpidem, Zopiclone, Zaleplon, etc.)這些相對來講更安全,藥效更快速,作用時間更短(這樣就比較不會有第二天昏沉的問題)的安眠藥物,雖然一開始號稱很安全,但隨著使用經驗增加,越來越多使用者出現夢遊的現象,而且,正因為他們藥效快速,所以成癮性比傳統的BZD類藥物更高,更難戒除。
近年來,有些朋友也嘗試過褪黑激素,這在美國您只要在超市或是藥房就可以買到,並不是處方用藥,當然相對也較安全。不過小布醫師藥提醒大家一下,由於褪黑激素台灣並未核准上市,所以不能拿來公然販售喔!
台灣目前核准的,是一種名為Ramelteon的藥物,姑且稱它是一種人工合成的褪黑激素,但其實它的強度是一般市售褪黑激素的3-6倍,也僅作用在M1, M2兩個特殊的接受體上,相對來說安全很多,也沒有傳統褪黑激素可能影響免疫力的副作用喔。
其實說了這麼多,小布醫師就是要提醒大家,睡不著、失眠絕對不是自己在家裡喝喝酒助眠就好,也不是隨便找個醫生開安眠藥,昨天吃一顆,今天心情比較差就自己再加一顆這樣亂亂來。小布醫師真心的希望各位民眾,如果有失眠的問題,請一定要尋求專業、專科醫師的諮詢與協助,身心科醫師都是很可愛、很關心民眾健康的,不會咬人喔,看身心科醫師沒有那麼可怕滴~~~
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洪凱駖藥師~ Solving a long-standing mystery about the desert’s rock art canvas Petroglyphs are carved in a material called rock varnish, the origins of which have been debated for years. Now, scientists argue it’s the result of bacteria and an adaptation that protects them from the desert sun’s harsh rays. By Nathan Collins 5923141600_1bc3f25867_k.jpg Rock art featuring human and animal forms and handprints Petroglyphs at Mesa Verde National Park, Colorado (Christine Fry & Peter Russo) Wander around a desert most anywhere in the world, and eventually you’ll notice dark-stained rocks, especially where the sun shines most brightly and water trickles down or dew gathers. In some spots, if you’re lucky, you might stumble upon ancient art – petroglyphs – carved into the stain. For years, however, researchers have understood more about the petroglyphs than the mysterious dark stain, called rock varnish, in which they were drawn. In particular, science has yet to come to a conclusion about where rock varnish, which is unusually rich in manganese, comes from. Now, scientists at the California Institute of Technology, the Department of Energy’s SLAC National Accelerator Laboratory and elsewhere think they have an answer. According to a recent paper in Proceedings of the National Academy of Sciences, rock varnish is left behind by microbial communities that use manganese to defend against the punishing desert sun. The mystery of rock varnish is old, said Usha Lingappa, a graduate student at Caltech and the study’s lead author. “Charles Darwin wrote about it, Alexander von Humboldt wrote about it,” she said, and there is a long-standing debate about whether it has a biological or inorganic origin. But, Lingappa said, she and her colleagues didn’t actually set out to understand where rock varnish comes from. Instead, they were interested in how microbial ecosystems in the desert interact with rock varnish. To do so, they deployed as many techniques as they could come up with: DNA sequencing, mineralogical analyses, electron microscopy, and – aided by Stanford Synchroton Radiation Lightsource (SSRL) scientist Samuel Webb – advanced X-ray spectroscopy methods that could map different kinds of manganese and other elements within samples of rock varnish. “By combining these different perspectives, maybe we could draw a picture of this ecosystem and understand it in new ways,” Lingappa said. “That’s where we started, and then we just stumbled into this hypothesis” for rock varnish formation. Among the team’s key observations was that, while manganese in desert dust is usually in particle form, it was deposited in more continuous layers in varnish, a fact revealed by X-ray spectroscopy methods at SSRL that can tell not only what chemical compounds make up a sample but also how they are distributed, on a microscopic scale, throughout the sample. That same analysis showed that the kinds of manganese compounds in varnish were the result of ongoing chemical cycles, rather than being left out in the sun for millennia. That information, combined with the prevalence of bacteria called Chroococcidiopsis that use manganese to combat the oxidative effects of the harsh desert sun, led Lingappa and her team to conclude that rock varnish was left behind by those bacteria. For his part, Webb said that he always enjoys a manganese project – “I’ve been a mangaphile for a while now” – and that this project arrived at the perfect time, given advances in X-ray spectroscopy at SSRL. Improvements in X-ray beam size allowed the researchers to get a finer-grained picture of rock varnish, he said, and other improvements ensured that they could get a good look at their samples without the risk of damaging them. “We’re always tinkering and fine-tuning things, and I think it was the right time for a project that maybe 5 or 10 years ago wouldn’t really have been feasible.” The research was supported by the National Science Foundation, the National Institutes of Health and the National Aeronautics and Space Administration. SSRL is a DOE Office of Science user facility. Citation: Usha F. Lingappa et al., Proceedings of the National Academy of Sciences, 22 June 2021 (10.1073/pnas.2025188118) For questions or comments, contact the SLAC Office of Communications at communications@slac.stanford.edu. SLAC is a vibrant multiprogram laboratory that explores how the universe works at the biggest, smallest and fastest scales and invents powerful tools used by scientists around the globe. With research spanning particle physics, astrophysics and cosmology, materials, chemistry, bio- and energy sciences and scientific computing, we help solve real-world problems and advance the interests of the nation. SLAC is operated by Stanford University for the U.S. Department of Energy’s Office of Science. The Office of Science is the single largest supporter of basic research in the physical sciences in the United States and is working to address some of the most pressing challenges of our time. X-ray Science X-ray Spectroscopy Stanford Synchrotron Radiation Lightsource (SSRL)